RAND Report - May 2013

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Emergency physicians are key decision makers for nearly half of all hospital admissions, highlighting a critical role they can play in reducing health care costs, according to a new report from the RAND Corporation. 

Hospital admissions from the ER increased by 17 percent over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009. Hospital inpatient care is a key driver of health care costs, accounting for 31 percent of the nation's health care expenses.

"This report tells policymakers and hospital administrators that they should pay closer attention to the role that emergency physicians play in evaluating, managing and preventing hospital admissions," said Dr. Andy Sama, president of the American College of Emergency Physicians. "Clearly, emergency departments must be fully integrated in health care delivery systems for both inpatient and outpatient care."

Hospital admissions grew from 34.7 million to 36.1 million, offset by a 10 percent decline in admissions from primary care physicians and clinical referrals. Nearly all of the increase was from "non-elective" admissions from the emergency department — a rate 3.8 times the rate of population growth. Increased admissions were highest among people ages 65 and older. Self-pay patients were less likely to be admitted to the hospital than patients with health insurance. The role ERs and emergency physicians play in deciding who to admit to the hospital is critical to hospital cost savings, since the average cost of an inpatient stay ($9,200) is roughly 10 times the average cost of a comprehensive emergency visit ($922).

The report also found that emergency care is important to physicians as well as patients. Four in five people who contacted a primary care physician or other medical provider before seeking emergency care were told to bypass their doctor's office and go directly to the emergency room. The RAND team found evidence that primary care physicians are increasingly relying on ERs to evaluate and, if necessary, hospitalize their sickest and most complex patients.

"One of the most important elements of patient-centered care is deciding when individuals can't be safely managed in community settings," said Dr. Wes Fields, chair of the Emergency Medicine Action Fund, which sponsored the RAND research. "Emergency physicians are trained to rapidly evaluate a wide array of conditions that are complex or time sensitive, and facilitate observation or admission of the most acutely ill patients. The study also suggests that the biggest challenge facing most ERs is trying to meet the needs of the growing population of Medicare age. Whether you live in a big city or a rural area, trying to find the right level of care for seniors with not one but several medical conditions is an ongoing struggle that plays out nights, weekends, and holidays at the front door to the hospital. Emergency departments are as vital as medical homes in every medical community."

Lack of access to follow-up care is a top concern that influences the decision of emergency physicians to admit particularly fragile patients to the hospital, rather than take a chance that they will fall through the cracks and suffer harm.

"The Rand report highlights the lack of follow-up care for many patients who come to the ER," said Dr. Alex Rosenau, president-elect of ACEP. "Sometimes physicians can send people home if they know their patients will be able to get their medications, have support from family or friends and can schedule follow-up medical visits. Sometimes these resources don't exist and we make decisions to admit. Emergency physicians coordinate transitions of care every day in hospitals across the country, filling the gaping holes in our health care system."

The report recommends that hospital administrators, policymakers, payers and federal research agencies recognize the current reality in emergency department operations and the role they play in coordinating care for millions of patients. 

The four percent of America's doctors who staff hospital emergency departments provide;

• 11 percent of all the outpatient visits in the United States,
• 28 percent of all acute care visits,
• half of the acute care visits by Medicaid and CHIP beneficiaries and
• two-thirds of all acute care visits by the uninsured.

"Efforts to reduce non-urgent and non-emergency use of emergency departments oversimplify a complex problem, and should instead focus on increasing access to affordable options outside the emergency room," said Dr. Sama.

Efforts to shift care into other facilities, such as retail clinics, have not always been successful because of the limitations of other facilities. For example, retail clinics lack diagnostic testing, are unable to admit patients to the hospital and won't see uninsured patients who can't pay cash.

The RAND Corporation is a nonprofit institution that helps improve policy and decision-making through research and analysis. RAND Health, a division of RAND Corporation, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics. The project was sponsored by the Emergency Medicine Action Fund, but RAND had full editorial control of its analysis and findings.